How do neurologists discuss functional symptoms with their patients: a conversation analytic study

Consultations with patients with functional symptoms can be challenging. This study describes some of the interactional and linguistic resources doctors use when they deliver the diagnosis of a functional disorder and recommend psychological treatment to patients presenting with medically unexplained neurological symptoms.

Twenty out-patient consultations between three experienced neurologists and patients with non-epileptic seizures (NES, N=17) or other functional neurological symptoms (FNS, n=3) were recorded and analysed using Conversation Analysis (CA). Encounters were split into activity sequences (1: history-taking; 2: discussion of examination and test results; 3: diagnosis; 4: aetiology; 5: treatment recommendations). The doctors' formulation effort (FE) in each activity sequence was graded (1: little, 2: some, 3: marked FE).

The doctors' communication behaviour was characterised by FE and accounting activities. FE increased during the course of the encounters and was most marked when doctors discussed the aetiology of symptoms and made psychological treatment recommendations. However, FE was evident even at the beginning of the encounters, and when patients fully aligned with the doctor.

This study provides interactional evidence why doctors may experience these consultations as challenging. While FE and accounting activities were sometimes linked to objective interactional problems (patients' resistance), doctors also seemed to engage in these practices for no clear interactional reasons, suggesting a degree of defensiveness or prior concern about the consultation. The extent of FE and accounting activities may display doctors' interactional distress but may also reflect a degree of delicacy when doctors explain the diagnoses of NES or FNS.